Tracheostomy¶

Jared Freitas

Indications¶

Improved pt comfort and decreased need for sedation
Reduced laryngeal damage
Increased ability to communicate (i.e. speaking valve)
May decrease risk of developing ventilator associated pneumonia (mixed data)
May reduce time to wean from the vent and decrease time in the hospital (mixed data)

No mortality difference or ↓ in hospital length of stay for early (day 4) vs late (day 10)
Generally performed after 2 weeks of intubation, but not backed by data
Pts that might get tracheostomy earlier: anticipated prolonged mechanical ventilation (i.e. those with acute neurologic injury affecting spinal cord)

Different brands: most common in hospital = Shiley
Components:
- Faceplate: keeps tube in place, has the model and size on it
- Inner cannula: can be removed, cleaned and replaced in case of obstruction
- Cuff (may or may not have): allows for pt to be ventilated; may prevent some aspiration
- Fenestration (may or may not have): allow speaking without valve
Common sizes:
- Initial: 8-0; Standard downsizing: 6-0
- Lengths: standard vs larger XLT (P = longer proximal end, D = longer distal end)
Presenting on ICU rounds = size/cuff status/brand (e.g. 8-0 cuffed shiley)

Passy Muir Valve (PMV): one-way valve placed on the outer portion of the trach; air moves in with inspiration but is blocked and thus funneled up through the vocal cords during exhalation allowing for phonation
Contraindication: severe upper airway obstruction or aspiration risk, copious secretions, decreased cognitive status, severe medical instability, or inability to tolerate cuff deflation
IMPORTANT SAFETY PRINCIPLE: cuff must be deflated, since air needs to be able to travel back up the airway, if the cuff is not deflated and you put the PMV on, then pt cannot exhale

Inner cannula should be cleaned 2-3 times per day
Daily stoma care should be initiated to prevent pressure ulcers and stoma infections
As needed suctioning for secretions

Hemorrhage (mild bleeding from surface vessels and granulation tissue is common, major bleeding is rare think erosion into brachiocephalic [innominate] artery)
Airway damage subglottic or tracheal stenosis; tracheobronchitis
Fistulas (tracheoarterial, tracheoesophageal)
Unintended tracheostomy tube dislodgement:
- Bag mask (use hand/gauze to occlude stoma) or intubate from above (i.e. through the mouth); if complete laryngectomy then must use stoma
- Fresh trach (≤ 14 days): do NOT replace due to risk of misplacement into the mediastinum and loss of airway; airway management from above
- Older trach: can be replaced at bedside with obturator by trained staff
- All pts with trachs have a yellow sign above bed with date, type, size of trach as well as a replacement trach with obturator in the room

Respiratory hygiene (“pulmonary toilet”): heated vent, guaifenesin, hypertonic saline, duonebs, cough assist device, appropriate suctioning (too much = worsen secretions), acapella, inspiratory spirometer

Last update: 2022-06-02 13:28:55